Executive Editor: Chris Colton

Authors: Florian Gebhard, Phil Kregor, Chris Oliver

Distal femur Partial articular fracture, frontal/coronal, posterior condyle(s)

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Glossary

General considerations

Posterior condylar fractures are serious intraarticular injuries in the weight bearing area of the knee joint. Direct open reduction for displaced fractures is mandatory to restore knee function. These fractures are technically challenging to reduce. It is not possible to treat these fractures by minimally invasive techniques.

The aim is anatomical restoration of the articular surface and early active mobilization of the joint.

Long leg cast then hinged knee brace
Indication summary Skill Equipment
Undisplaced fracture, low demand patient Basic surgical experience, no specialized skills Basic equipment only

Most distal femoral fractures are treated surgically. Nonoperative treatment is reserved for exceptional cases, e.g., if the general medical condition does not allow safe anesthesia. If nonoperative treatment is selected, a long leg splint, followed by a hinged knee brace should be used to minimize limb shortening and to provide pain relief.

Indication

  • Undisplaced fracture in patients not medically fit for surgery

Disadvantages

  • Risk of knee stiffness
  • Risk of secondary displacement
  • Risk of thrombo-embolism
Temporary long leg splint
Indication summary Skill Equipment
Displaced fracture, medically unfit patient Basic surgical experience, no specialized skills Basic equipment only

In occasional cases, a period of temporary splintage may be necessary before the patient’s general condition, or the local status of the soft-tissues, will permit safe surgery.

Indications

  • Patient in extremis
  • Significant shortening, or angulation, without operative management

Contraindications

  • Safe definitive fixation possible
  • Severe local soft-tissue compromise

Advantages

  • Easy to apply
  • Quick and safe procedure

Disadvantages

  • Pressure sores
  • Potential knee stiffness
  • Risk of shortening
Temporary external fixator
Indication summary Skill Equipment
Damage control Some specialized surgical experience Simple surgical and imaging resources

Intraarticular fractures should be anatomically reduced when this is possible.

In occasional cases, a period of nonoperative treatment may be necessary before the patient’s general condition, or the local status of the soft-tissues, will permit safe surgery. In these patients, temporary external fixation may be useful.

Further indication

  • Associated vascular injury

Contraindication

  • Existing prosthesis/implant conflicting with pin tracks

Advantages

  • Minimally invasive
  • Rapid procedure

Disadvantages

  • Potential knee stiffness
  • Fixator pins may compromise sterility, future incisions, or definitive fixation
ORIF - anterior screws for large fragments
Indication summary Skill Equipment
Displaced large fragments Highly experienced and skilled surgeon Simple surgical and imaging resources

Larger fragments can be approached from anterior. Even undisplaced fractures should be fixed with lag screws, as they will invariably displace with nonoperative treatment. The aim is anatomical restoration of the articular surface and early active mobilization of the joint.

Indications

  • All posterior condylar fractures
  • Additional knee ligament injury
  • Additional meniscial injury

Contraindications

  • Patient not medically fit for surgery
  • Small fragments (should be addressed from posterior)
  • Pathological fractures due to bone tumor in the femoral condyle (giant cell tumor of bone)

Advantages

  • Direct anatomical reduction
  • Early mobilization of the knee joint
  • Lower risk of degenerative joint disease
ORIF - posterior screws for small fragments
Indication summary Skill Equipment
Displaced small fragments Highly experienced and skilled surgeon Simple surgical and imaging resources

Undisplaced small fractures should be fixed with sunken screws or bioresorbable pins, so that anatomical restoration of the articular surface can be achieved and early active mobilization of the joint surface undertaken

Indications

  • Small fragments
  • Displaced and undisplaced fractures (any undisplacedposterior condylar fracture is likely to displace without fixation)

Contraindications

  • Patient not medically fit for surgery
  • Pathological fractures due to bone tumor in the femoral condyle (giant cell tumor of bone)

Advantages

  • Direct anatomical reduction
  • Early mobilization of the knee joint
  • Lower incidence of osteoarthritis

Disadvantages

  • Difficult surgical approach
  • Cannot deal with anterior cruciate ligament and meniscial injuries via posterior approach
  • More visible scarring
  • Risk of knee joint stiffness
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2008-12-03